Asherman’s Syndrome On Ultrasound | Key Signs And Limits

When scarring bridges the uterine cavity, ultrasound can show thin bands, angular cavity distortion, and poor endometrial lining. When you document “asherman’s syndrome on ultrasound,” spell out the bands, the cavity shape, and the endometrial response so decisions are clear. Knowing these patterns helps you decide when to refer for hysteroscopy, how to counsel on fertility, and which alternative diagnoses to rule out.

Asherman’s Syndrome On Ultrasound: Quick Orientation

Asherman’s syndrome refers to intrauterine adhesions that form after instrumentation, infection, or trauma. On grayscale ultrasound, you may see echogenic bands that tether opposing walls or a partial cavity obliteration. With color Doppler, these bands are typically avascular.

Asherman’s Syndrome Ultrasound Findings And Caveats

This section summarizes the typical sonographic signs, their meaning, and practical scanning notes. Use transvaginal imaging first for resolution, then add saline infusion sonohysterography (SIS) or 3D volume sweeps if the cavity looks distorted or the endometrium is not well visualized.

Core Clues You Can See

Below is a compact table of common features and why they matter.

Feature	How It Appears	Why It Matters
Echogenic Bands	Thin, bright lines spanning the cavity; may cast a faint shadow	Typical for adhesions; often the first hint
Angular Cavity Distortion	Irregular, kinked contour of the endometrial cavity	Suggests tethering that can affect implantation
Interrupted Endometrial Stripe	Discontinuous or thinned functional layer	Implies reduced endometrial growth potential
Nonmobile Strands	Persistent bands that do not float with probe pressure	Supports scar rather than mucus or clot
Avascular Bands On Doppler	No internal flow within the strand	Helps separate scarring from polyp or placental tissue
Focal Cavity Obliteration	Portion of the cavity not distending with fluid	Correlates with more severe disease
Thin Endometrium In Luteal Phase	Sub-optimal thickness when it should be thick	Indirect clue; supports the diagnosis
Asymmetric Fundus	One side pulled inward by a bridge	Explains pain or infertility in some patients

How To Scan For The Best Answer

Start with transvaginal B-mode. Sweep the endometrium slowly in sagittal and coronal planes and adjust gain to avoid blooming. If bands are suspected, apply color Doppler with a low pulse repetition frequency to test for flow. When the cavity outline is unclear, perform saline infusion sonohysterography; the fluid outlines the walls and reveals non-distending segments. If your system supports it, capture a 3D volume for multiplanar review and surface rendering. These steps make your call more confident and reproducible.

Why The History Matters Before You Call It

The diagnosis sits on pictures and context. Ask about prior dilation and curettage, retained placenta management, cesarean scar revisions, endometritis, or pelvic tuberculosis depending on region. Timing also matters; early post-procedure scans may show transient debris, while fixed avascular bands persisting across cycles fit adhesions better. Build the story, then commit to the label.

Grades, Symptoms, And What The Images Predict

Severity ranges from lacy strands to near occlusion. Patients can have hypomenorrhea, cyclical pelvic pain, infertility, or recurrent loss. Sonographic severity often tracks with symptom burden. Dense, broad-based scars tend to reduce cavity volume and dampen the endometrium’s response, which can lower implantation chances. Thin, filmy bridges may be treatable in the office; sheet-like occlusions usually need operative hysteroscopy.

When Imaging Alone Is Not Enough

Ultrasound gives you the first map, but hysteroscopy confirms and treats. If the cavity cannot distend or the endometrium looks chronically thin with persistent bands, a referral is sensible. Many services perform directed lysis with micro-scissors, then place a barrier and start a short estrogen course to promote healing.

Ruling Out Look-Alikes On Ultrasound

Several conditions can mimic adhesion bands. Fibroids, polyps, arcuate or septate anatomy, and retained products can all produce lines, shadows, or distortion. Use mobility, vascularity, and response to saline to sort them. Polyps tend to show a pedicle artery; submucous fibroids are firm, round, and shadow. Congenital partitions are smooth, symmetric, and fixed from fundus downward.

Common Pitfalls That Lead To Misses

Two errors pop up often. First, calling mobile mucus a scar; probe pressure and the fluid test help avoid that. Second, underestimating the extent; a single plane can hide bridges that only 3D or SIS reveals. When fertility plans are time-sensitive, err on the side of full cavity mapping.

Treatment Pathways And What Imaging Adds

Once Asherman’s syndrome is on the table, imaging should tell the surgeon where and how broad the adhesions are, whether the cornua are patent, and if there is residual endometrium to build upon. Post-lysis, ultrasound checks cavity re-expansion and endometrial regrowth. If bleeding normalizes and the lining reaches appropriate thickness, the outlook improves.

Evidence And Guidance You Can Trust

Professional bodies support this flow. The ACOG hysteroscopy guidance explains office and operative use for intrauterine pathology, and the NCBI StatPearls review on Asherman syndrome outlines causes, evaluation, and care pathways.

Table Of Confounders And How To Tell Them Apart

Use this quick comparator when a bright line shows up in the cavity. It keeps to three columns and favors clues you can check in the same session.

Condition	Suggestive Clues	Tip To Differentiate
Endometrial Polyp	Focal echogenic mass; smooth outline	Feeding vessel on color Doppler; mobile with saline
Submucous Fibroid	Round, hypoechoic, edge shadowing	Firm, broad-based, often distorts serosa
Septate/Arcuate Uterus	Smooth midline indentation from fundus	Symmetric, fixed contour; present life-long
Retained Products	Heterogeneous tissue; possible vascularity	Flow within lesion and clinical context of pregnancy
Blood Clot	Low-level echoes; shape changes with pressure	No internal flow; melts or shifts with time
Synechiae In Pregnancy	Thin band with amniotic drape	Often incidental; do not tether cavity outside pregnancy
Endometritis	Thick, irregular endometrium	Clinical signs and diffuse vascularity
Adenomyosis	Heterogeneous myometrium, myometrial cysts	Junctional zone changes; cavity intact

Reporting Template You Can Adapt

Clear, structured language speeds decisions. Use a short template like this:

Indication

Infertility with suspected intrauterine adhesions after dilation and curettage.

Technique

Transvaginal pelvic ultrasound with color Doppler. Saline infusion sonohysterography performed. 3D volume acquired.

Findings

Echogenic bands traversing the mid-cavity, avascular on Doppler. Partial failure of cavity distension on SIS along the anterior wall. Endometrial thickness sub-optimal for phase. No focal polypoid mass or submucous fibroid identified. Tubal ostia areas visible but slightly narrowed.

Impression

Findings suggest intrauterine adhesions consistent with Asherman’s syndrome. Referral for hysteroscopic lysis with post-procedure ultrasound follow-up is suggested.

Counseling Points Patients Want Answered

People ask whether the condition always means infertility or if cycles will return to normal. Outcomes vary with severity and the amount of healthy lining that remains. Mild disease often responds well to lysis, while extensive scarring can need staged procedures. After treatment, ultrasound helps confirm that the cavity distends, the lining thickens, and the bleed pattern improves. Set expectations clearly and share the plan for imaging checkpoints.

When To Escalate And Whom To Involve

Escalate early if the cavity looks nearly sealed, if saline cannot pass, or if the patient has repeated loss. A fertility surgeon or a gynecologist with hysteroscopy expertise should lead care. Radiology, sonography, and reproductive endocrinology teams work together to time scans with the cycle, document progress, and plan interventions.

Limitations Of Ultrasound For This Diagnosis

Ultrasound can miss thin filmy adhesions, especially without SIS. It also struggles when the cavity is full of blood or infection. In tough cases, diagnostic hysteroscopy remains the reference. MRI may help with congenital anomalies or deep myometrial disease but is not the first stop when the question is intrauterine adhesions.

Practical Takeaways For Busy Clinics

Use a stepwise approach: targeted history, high-quality transvaginal imaging, add SIS for mapping, and capture a 3D volume when available. If findings match asherman’s syndrome on ultrasound and symptoms fit, refer for hysteroscopy and plan follow-up imaging after treatment.